Provider Demographics
NPI:1417643164
Name:MASSEY, MIRANDA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MASSEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14130 23RD AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447
Mailing Address - Country:US
Mailing Address - Phone:763-383-7666
Mailing Address - Fax:763-383-6013
Practice Address - Street 1:14130 23RD AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447
Practice Address - Country:US
Practice Address - Phone:763-383-7666
Practice Address - Fax:763-383-6013
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107151225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics